﻿@model Adams.Public.DataTransfer.Web.Security.Signup.PageLoad
@{
    ViewBag.Title = "Login";
    Layout = "~/Views/Shared/_AppLayout.cshtml";
}
@section Head{
}
<h1>
    Sign Up</h1>
<div id="form">
    <div class="form-left">
        <div class="form-text">
            <span class="required">*</span>First Name:</div>
        <div class="form-right">
            <input type="text" value="" class="input" id="FirstName" />
        </div>
    </div>
    <div class="form-left">
        <div class="form-text">
            <span class="required">*</span>Last Name:</div>
        <div class="form-right">
            <input type="text" value="" class="input" id="LastName" />
        </div>
    </div>
    <div class="form-left">
        <div class="form-text">
            <span class="required">*</span>Email:</div>
        <div class="form-right">
            <input type="text" value="" class="input" id="Email" />
        </div>
    </div>
    <div class="form-left">
        <div class="form-text">
            <span class="required">*</span>Street:</div>
        <div class="form-right">
            <input type="text" value="" class="input" id="Street" />
        </div>
    </div>
    <div class="form-left">
        <div class="form-text">
            Street2:</div>
        <div class="form-right">
            <input type="text" value="" class="input" id="Street2" />
        </div>
    </div>
    <div class="form-left">
        <div class="form-text">
            <span class="required">*</span>City:</div>
        <div class="form-right">
            <input type="text" value="" class="input" id="City" />
        </div>
    </div>
    <div class="form-left">
        <div class="form-text">
            <span class="required">*</span>State:</div>
        <div class="form-right">
            <select name="State" class="option" id="State">
                <option value="AL">Alabama</option>
                <option value="AK">Alaska</option>
                <option value="AZ">Arizona</option>
                <option value="AR">Arkansas</option>
                <option value="CA">California</option>
                <option value="CO">Colorado</option>
                <option value="CT">Connecticut</option>
                <option value="DE">Delaware</option>
                <option value="DC">District of Columbia</option>
                <option value="FL">Florida</option>
                <option value="GA">Georgia</option>
                <option value="HI">Hawaii</option>
                <option value="ID">Idaho</option>
                <option value="IL">Illinois</option>
                <option value="IN">Indiana</option>
                <option value="IA">Iowa</option>
                <option value="KS">Kansas</option>
                <option value="KY">Kentucky</option>
                <option value="LA">Louisiana</option>
                <option value="ME">Maine</option>
                <option value="MD">Maryland</option>
                <option value="MA">Massachusetts</option>
                <option value="MI">Michigan</option>
                <option value="MN">Minnesota</option>
                <option value="MS">Mississippi</option>
                <option value="MO">Missouri</option>
                <option value="MT">Montana</option>
                <option value="NE">Nebraska</option>
                <option value="NV">Nevada</option>
                <option value="NH">New Hampshire</option>
                <option value="NJ">New Jersey</option>
                <option value="NM">New Mexico</option>
                <option value="NY">New York</option>
                <option value="NC">North Carolina</option>
                <option value="ND">North Dakota</option>
                <option value="OH">Ohio</option>
                <option value="OK">Oklahoma</option>
                <option value="OR">Oregon</option>
                <option value="PA">Pennsylvania</option>
                <option value="RI">Rhode Island</option>
                <option value="SC">South Carolina</option>
                <option value="SD">South Dakota</option>
                <option value="TN">Tennessee</option>
                <option value="TX">Texas</option>
                <option value="UT">Utah</option>
                <option value="VT">Vermont</option>
                <option value="VA" selected>Virginia</option>
                <option value="WA">Washington</option>
                <option value="WV">West Virginia</option>
                <option value="WI">Wisconsin</option>
                <option value="WY">Wyoming</option>
            </select>
        </div>
    </div>
    <div class="form-left">
        <div class="form-text">
            <span class="required">*</span>Zip Code:</div>
        <div class="form-right">
            <input type="text" value="" class="input" id="ZipCode" />
        </div>
    </div>
    <div class="form-left">
        <div class="form-text">
            <span class="required">*</span>Phone:</div>
        <div class="form-right">
            <input type="text" value="" class="input" id="Phone" />
        </div>
    </div>
    <div class="form-left">
        <div class="form-text">
            <span class="required">*</span>Password:</div>
        <div class="form-right">
            <input type="password" value="" class="input" id="Password1" />
        </div>
    </div>
    <div class="form-left">
        <div class="form-text">
            <span class="required">*</span>Confirm Password:</div>
        <div class="form-right">
            <input type="password" value="" class="input" id="Password2" />
        </div>
    </div>
    <div class="form-left">
        <div class="form-text">
            <span class="required">*</span>Security Check:</div>
        <div class="form-right">
            <img id="captcha" src="/Security/Captcha" />
            <input id="captcharefresh" type="image" src="/content/images/captcha_refresh.png" />
            <br />
            <input type="text" value="" class="input" id="Captcha" />
        </div>
    </div>
    <div class="form-left">
        <div class="form-text">
            &nbsp;</div>
        <div class="form-right">
            <a href="#">
                <img src="/Content/Images/submit.jpg" alt="Submit" border="0" id="signupsubmit" /></a></div>
    </div>
    <div class="clear">
    </div>
</div>
@section Scripts {
    <script type="text/javascript" src="@Url.Content("/Scripts/Security/signup.js")"></script>
}
